Checklist Encourages Better Birth Practices in India

But BetterBirth program had no impact on mortality rates or complications

Birth attendants who received a coaching intervention designed to improve facility-based childbirth care had higher adherence to essential birth practices compared with those who didn't, according to a cluster-randomized trial in India.

After 2 months of twice-weekly coaching, birth attendants who followed the BetterBirth program, a coaching-based implementation of the World Health Organization's Safe Childbirth Checklist performed 72.8% of the 18 measured practices, whereas birth attendants in control facilities performed just 41.7% of the practices (P<0.001), reported Katherine E.A. Semrau, PhD, MPH, of Harvard Medical School and Director of BetterBirth.

Four months after coaching ended, the intervention facilities continued to perform more essential birth practices, although the control facilities remained the same (61.7% versus 43.9%; P<0.001), Semrau and colleagues wrote online in the New England Journal of Medicine.

Yet while Semrau said the intervention led to "significant improvements in care for women and newborns," it didn't reduce either mortality or birth complications.

"With moving quality of care in the right direction, we can focus on additional requirements to impact mortality," she said.

Co-author Vishwajeet Kumar, MD, MPH, executive director of the Community Empowerment Lab in Lucknow, India, agreed that the results show that major improvements in the quality of childbirth are possible: "We can build on this progress with initiatives that further strengthen the health system and provide the missing links required for reductions in mortality."

"This was the first rigorous study of deploying checklists and coaching at large scale," commented Atul Gawande, MD, Harvard T.H. Chan School of Public Health and Ariadne Labs Executive Director, who helped develop the Safe Childbirth Checklist. "The results demonstrated impressive behavior change. Now we in public health must identify the additional ingredients required to produce the complete recipe for saving lives at childbirth."

Semrau and colleagues conducted the study at 120 primary care centers and first referral units in Uttar Pradesh, India, from 2014 to 2016. Birth attendants and managers at 60 government health centers were coached on the BetterBirth program, while 60 matched facilities served as comparison sites and received the existing standard of care. Data on more than 300,000 women and babies were included in the analysis.

The researchers evaluated Checklist essential birth practices (i.e., handwashing and taking temperature), rates of maternal and perinatal death within seven days of delivery, and maternal complications within seven days of delivery (i.e., seizures, loss of consciousness for more than an hour, fever with foul-smelling vaginal discharge).

Coaches recorded birth attendant performance, and birth attendance performance data was provided in real-time as supportive feedback to birth attendants, facility managers, and district health officials.

While resource availability was similar in the two trial groups, birth attendants performed most specific practices at significantly higher rates in the intervention group than in the control group. In intervention sites, the checklist was used at admission in 56.8% of observed births and within the first hour after delivery in 74.3% of observed births.

Nevertheless, maternal and neonatal mortality rates or maternal complications within 7 days did not differ (15.1% in the intervention group and 15.3% in the control group), nor did a composite of perinatal and maternal death within 7 days (4.91% versus 4.71%, respectively).

The researchers cited several factors which may have affected the results, including that levels of adherence to essential birth practices in the intervention sites may have been insufficient to affect outcomes.

Study limitations included data available for only a select sub-sample of deliveries and the possibility of misreporting since the researchers did not verify reported complications with medical records or physical examinations.

The research was led by Ariadne Labs, a joint center of the Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital in Boston, and the Governments of India and Uttar Pradesh and the World Health Organization. It was supported by the Bill & Melinda Gates Foundation.

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